Global & Disaster Medicine

Archive for the ‘Public Health’ Category

“…….Mississippi adopted its first compulsory vaccination law in 1900, adding a religious exemption in 1960. Almost 20 years later, in 1979, the religious exemption was challenged in court, with the plaintiff arguing that the state must expand the exemption to include any religion, not just religions officially recognized by the state. In response, the Mississippi Supreme Court struck down religious exemptions altogether, ruling that non-medical vaccine exemptions violate people’s constitutional right to equal protection under the law.

The decision was a big win for public health, but it certainly has not stopped attempts to water down Mississippi’s vaccine rules…..”

“…..Communities began to lead and fund their own health centers. In their first four years, village health centers saw 3.5 million patient visits, including those associated with a program to screen more than 100 thousand children for nutritional and physical wellbeing. These centers have become a training and employment ground for young people who otherwise would have moved to urban areas.

After just 12 years, the Emergency Management and Research Institute (EMRI), has deployed more than 10,000 ambulances and 45,000 skilled personnel to respond to 56.1 million emergencies, save 2.3 million lives, serve 18.9 million pregnant women, and assist in 480 thousand births.

They have done this through a centralized, call-in system that receives 150,000 calls and responds to nearly 25,000 emergencies each day. Users can call into a free, emergency 108 telephone number, which provides integrated medical, police, and fire emergency services. A single call center can provide service for up to fifty million people at a cost of $0.25 USD per person per year. The service is free to the user and costs the provider less than $15 USD per emergency. This is less than one percent of what an emergency call costs in the United States…..”

“…..a 65% increase in maternal mortality and a 30% increase in infant mortality, with 11 466 infants dying during 2016. It also revealed that while Venezuela had been the first country in the world to eliminate malaria in populated areas, this and other diseases such as diphtheria, which had previously been controlled, had returned in several outbreaks.…..most laboratory services and hospital nutrition services are only available intermittently or are completely inoperative. Shortages of items such as basic medicines, catheters, surgical supplies, and infant formula are highlighted in the survey; 14% of intensive care units have been shut down because they are unable to operate and 79% of the facilities analysed have no water at all.……..”

Despite improvements in two-thirds of states, significant inequities in health security exist across the nation: the highest-scoring state (Maryland, 8.0) scores 25 percent higher than the lowest states (Alaska and Nevada, 6.4). Generally, states in the Deep South and Mountain West regions lag behind Northeast and Pacific Coast states. Many of the lower-scoring states face elevated risks of disasters and contain disproportionate numbers of low-income residents.

“Five years of continuous gains in health security nationally is remarkable progress,” said Glen Mays, PhD, MPH, who leads a team of researchers at the University of Kentucky in developing the Index. “But achieving equal protection across the U.S. population remains a critical unmet priority.”

Eighteen states achieved preparedness levels that exceed the national average, with 21 states below the national average. A total of 38 states plus the District of Columbia increased their overall health security in the last year, while eight remained steady and four states declined.

“Every community must be equipped to prepare for, respond to, and recover from any health emergency,” said Stephen C. Redd, MD, RADM, USPHS, director of the U.S. Centers for Disease Control and Prevention (CDC) Office of Public Health Preparedness and Response. “The Index helps pinpoint where cross-sector investments are paying off and how the nation can increase resilience.”

Based on a model informed by experts in public health, emergency management, academia, health care, and other sectors, researchers collect, aggregate, and measure health security data from more than 50 sources. The final measures fall into six categories, each of which is assessed independently, and cover topics such as:

Originally developed by the CDC as a tool to drive dialogue to improve health security and preparedness, the Index is a collaborative effort funded by RWJF involving more than 30 organizations. State health officials, emergency management experts, business leaders, nonprofits, researchers, and others help shape the Index.

“…..the country does not invest enough to maintain strong, basic core capabilities for health security readiness and, instead, is in a continued state of inefficiently reacting with federal emergency supplemental funding packages each time a disaster strikes.

According to Ready or Not?, federal funding to support the base level of preparedness has been cut by more than half since 2002, which has eroded advancements and reduced the country’s capabilities…..

The report card is based on 10 key indicators of public health preparedness. Half of all states scored a 5 or lower (out of 10), with Alaska scoring the lowest (2), and Massachusetts and Rhode Island scoring the highest (9). Delaware, North Carolina, and Virginia each scored 8 out of 10. Florida received a 6.….

Some key findings include:

Just 19 states and Washington, D.C. increased or maintained funding for public health from Fiscal Year (FY) 2015-2016 to FY 2016-2017.

The primary source for state and local preparedness for health emergencies has been cut by about one-third (from $940 million in FY 2002 to $667 million in FY 2017) and hospital emergency preparedness funds have been cut in half ($514 million in FY 2003 to $254 million in FY 2017).

In 20 states and Washington, D.C. 70 percent or more of hospitals reported meeting Antibiotic Stewardship Program core elements in 2016.

Just 20 states vaccinated at least half of their population (ages 6 months and older) for the seasonal flu from Fall 2016 to Spring 2017—and no state was above 56 percent.

The Ready or Not? report provides a series of recommendations that address many of the major gaps in emergency health preparedness, including:

Communities should maintain a key set of foundational capabilities and focus on performance outcomes in exchange for increased flexibility and reduced bureaucracy.

Ensuring stable, sufficient health emergency preparedness funding to maintain a standing set of core capabilities so they are ready when needed. In addition, a complementary Public Health Emergency Fund is needed to provide immediate surge funding for specific action for major emerging threats.

Strengthening and maintaining consistent support for global health security as an effective strategy for preventing and controlling health crises. Germs know no borders.

Innovating and modernizing infrastructure needs – including a more focused investment strategy to support science and technology upgrades that leverage recent breakthroughs and hold the promise of transforming the nation’s ability to promptly detect and contain disease outbreaks and respond to other health emergencies.

Recruiting and training a next generation public health workforce with expert scientific abilities to harness and use technological advances along with critical thinking and management skills to serve as Chief Health Strategist for a community.

Preventing the negative health consequences of climate change and weather-related threats. It is essential to build the capacity to anticipate, plan for and respond to climate-related events.

Prioritizing efforts to address one of the most serious threats to human health by expanding efforts to stop superbugsand antibiotic resistance.

Improving rates of vaccinations for children and adults – which are one of the most effective public health tools against many infectious diseases.

Supporting a culture of resilience so all communities are better prepared to cope with and recover from emergencies, particularly focusing on those who are most vulnerable. Sometimes the aftermath of an emergency situation may be more harmful than the initial event. This must also include support for local organizations and small businesses to prepare for and to respond to emergencies…….”

Summary
The Centers for Disease Control and Prevention (CDC) is working with federal, state, territorial, and local agencies and global health partners in response to recent hurricanes. CDC is aware of media reports and anecdotal accounts of various infectious diseases in hurricane-affected areas, including Puerto Rico and the US Virgin Islands (USVI). Because of compromised drinking water and decreased access to safe water, food, and shelter, the conditions for outbreaks of infectious diseases exist.

The purpose of this HAN advisory is to remind clinicians assessing patients currently in or recently returned from hurricane-affected areas to be vigilant in looking for certain infectious diseases, including leptospirosis, dengue, hepatitis A, typhoid fever, vibriosis, and influenza. Additionally, this Advisory provides guidance to state and territorial health departments on enhanced disease reporting.

Background
Hurricanes Irma and Maria made landfall in Puerto Rico and USVI in September 2017, causing widespread flooding and devastation. Natural hazards associated with the storms continue to affect many areas. Infectious disease outbreaks of diarrheal and respiratory illnesses can occur when access to safe water and sewage systems are disrupted and personal hygiene is difficult to maintain. Additionally, vector borne diseases can occur due to increased mosquito breeding in standing water; both Puerto Rico and USVI are at risk for outbreaks of dengue, Zika, and chikungunya.

Health care providers and public health practitioners should be aware that post-hurricane environmental conditions may pose an increased risk for the spread of infectious diseases among patients in or recently returned from hurricane-affected areas; including leptospirosis, dengue, hepatitis A, typhoid fever, vibriosis, and influenza. The period of heightened risk may last through March 2018, based on current predictions of full restoration of power and safe water systems in Puerto Rico and USVI.

In addition, providers in health care facilities that have experienced water damage or contaminated water systems should be aware of the potential for increased risk of infections in those facilities due to invasive fungi, nontuberculous Mycobacterium species, Legionella species, and other Gram-negative bacteria associated with water (e.g., Pseudomonas), especially among critically ill or immunocompromised patients.

Cholera has not occurred in Puerto Rico or USVI in many decades and is not expected to occur post-hurricane.

Recommendations

These recommendations apply to healthcare providers treating patients in Puerto Rico and USVI, as well as those treating patients in the continental US who recently traveled in hurricane-affected areas (e.g., within the past 4 weeks), during the period of September 2017 – March 2018.

Health care providers and public health practitioners in hurricane-affected areas should look for community and healthcare-associated infectious diseases.

Health care providers in the continental US are encouraged to ask patients about recent travel (e.g., within the past 4 weeks) to hurricane-affected areas.

All healthcare providers should consider less common infectious disease etiologies in patients presenting with evidence of acute respiratory illness, gastroenteritis, renal or hepatic failure, wound infection, or other febrile illness. Some particularly important infectious diseases to consider include leptospirosis, dengue, hepatitis A, typhoid fever, vibriosis, and influenza.

In the context of limited laboratory resources in hurricane-affected areas, health care providers should contact their territorial or state health department if they need assistance with ordering specific diagnostic tests.

For certain conditions, such as leptospirosis, empiric therapy should be considered pending results of diagnostic tests— treatment for leptospirosis is most effective when initiated early in the disease process. Providers can contact their territorial or state health department or CDC for consultation.

Local health care providers are strongly encouraged to report patients for whom there is a high level of suspicion for leptospirosis, dengue, hepatitis A, typhoid, and vibriosis to their local health authorities, while awaiting laboratory confirmation.

Confirmed cases of leptospirosis, dengue, hepatitis A, typhoid fever, and vibriosis should be immediately reported to the territorial or state health department to facilitate public health investigation and, as appropriate, mitigate the risk of local transmission. While some of these conditions are not listed as reportable conditions in all states, they are conditions of public health importance and should be reported.